Partners in Prevention: International Case Studies of Effective Health Promotion Practice in HIV/AIDS

Foreword

The Contexts of Community Mobilization and HIV/AIDS Prevention

Experience from Australia

Experience from Canada

Experience from Thailand

Experience from Uganda

Prevention in Practice: Summation of Guiding Principles

Resources List

Experience from Australia

by Lou McCallum, Executive
Director,Australian Federation of AIDS Organisations, and Don
Baxter,former Executive Director, AIDS Council of New South Wales
Sydney, Australia

OVERVIEW AND CONTEXT

HIV epidemiology

It is estimated that there were 11,080 people living with HIV
infection in Australia at the end of 1996. HIV incidence is thought to have
peaked in 1994 and a slow but steady decrease in incidence is expected over the
next few years. The cumulative number of HIV infections in Australia to the end
of 1996 was 16,700, and 95% of these are in men. Incidence of HIV is not evenly
distributed geographically across Australia, but concentrated in particular
States and cities: 63% of people with HIV reside in New South Wales, 18% in
Victoria, and 9% in Queensland-in order, the three largest States. There have
been 7,532 people diagnosed with AIDS in Australia since the first case was
identified in 1982, and 96% of these were men. Of these, 5,373 have died.

The number of new diagnoses of HIV infection is around 500 cases
per year, and there are approximately 200 newly acquired HIV infections each
year, i.e. infections definitely acquired only in the previous twelve months.
Transmission of HIV in Australia continues to be predominantly linked to sexual
contact between men. Over 85% of all HIV transmission in Australia is thought to
have occurred this way. Needle-sharing during injecting drug use is the second
most common mode of transmission, accounting for approximately five new
infections per year (National Centre in HIV Epidemiology and Clinical Research
1997).

Key organizations and players

The response to AIDS in Australia has been characterized by a
partnership between government, health providers, researchers and affected
communities. The national approach has been guided by successive national
HIV/AIDS strategies since 1989, based on a set of principles, policy guidelines
and activities developed from 1985 onwards. These strategies have set out basic
principles, including the non-partisan political approach to HIV/AIDS, the
partnership with non-governmental organizations and the affected communities,
and the central role of people with HIV/AIDS in the response.

Australia is divided into six States and two Territories. These
States and Territories have responsibility for health service provision. The
federal government allocates funds to the States and Territory governments for
HIV/AIDS initiatives under the strategy. Currently, State and Territory
governments are committed under the strategy to match these funds dollar for
dollar. The range of government and non-governmental organizations involved in
Australia's response are listed in the table below.

State and Territory AIDS Councils, PLWHAorganizations, sex
worker and injecting drug use (IDU)organizations

The federal government funds the peak NGO body, the Australian
Federation of AIDS Organisations (AFAO), and State and Territory governments
fund State and Territory NGOs. AFAO's role is to advocate at a national level on
behalf of NGOs. The other national peak NGOs which are members of AFAO are:
Australian IV League (AIVL), a national organization representing the interests
of injecting drug users; National Association of People with HIV/AIDS (NAPWA),
the peak PLWHA group; and Scarlet Alliance, a national group representing sex
workers.

Each State and Territory has an AIDS Council, which is a
community-based NGO responsible for HIV education and care and support
activities. AIDS Councils were formed by early 1986 by members of the gay
communities in each State and Territory capital city with funding from State and
Territory governments. The work of the councils is usually divided between
education and prevention activities in the gay community and the care and
support of PLWHAs. Gradually, PLWHA, sex worker and injecting drug-users' (IDU)
community organizations were set up in most States and Territories. Sex worker
and IDU organizations focused on education, prevention and advocacy activities
among their particular target groups, and PLWHA organizations generally provided
information, support and advocacy for PLWHAs. In some States and Territories,
representatives from AIDS Councils, PLWHA, sex worker and IDU organizations were
invited to participate in State AIDS policy advisory committees, which
coordinated programme and policy development at State level.

In 1987, State and Territory AIDS Councils joined with the
national PLWHA, IDU and sex worker organizations to form AFAO, which would be
responsible for advocating on behalf of AIDS community organizations at a
national level and for facilitating communication between State and Territory
community organizations. Since that time, AFAO has participated in successive
national AIDS advisory committees and in the establishment and review of the
first, second and third national AIDS strategies. AFAO has developed a strong
partnership with the Commonwealth Department of Health and with successive
Commonwealth Health Ministers.

History and structure of the community-based response

The first case of AIDS was diagnosed in Sydney in 1982. The gay
community in Sydney had recently won a long battle for anti-discrimination law
reform and had a range of community organizations and structures which were able
to be mobilized to respond to HIV/AIDS. Similar organizations were established
by this time in other Australian capital cities. As gay men were being diagnosed
with HIV infection or AIDS in Sydney and Melbourne hospitals, volunteers from
gay organizations were asked to help with emotional and practical support. Gay
men and their friends began forming groups to provide home care and emotional
and financial support. Existing gay groups such as the Sisters of Perpetual
Indulgence (an Order of gay male nuns) obtained safe sex materials for similar
organizations in the United States and modified them for Australia. A
newly-formed AIDS charity, the Bobby Goldsmith Foundation, also produced a safe
sex pamphlet in 1984-the first Australian material of its kind and funded by the
gay community.

A group called the AIDS Action Committee was formed in Sydney
and eventually became the AIDS Council of New South Wales (ACON) in 1985. At
about this time, the Federal Health Minister, Dr Neal Blewett, travelled to San
Francisco and was convinced that a collaboration between government and the
affected communities in Australia would be essential to dealing with AIDS. A gay
charity and a volunteer care and support organization had already been formed in
response to increasing numbers of gay men being diagnosed with AIDS. ACON
attracted a small grant direct from the Commonwealth Government and began to
produce campaign materials targeted at gay men from 1985 onwards. Eventually,
the New South Wales State government took over funding of ACON so that it could
produce prevention materials, hold safe sex workshops, advocate for policy
development and train volunteers to care for people with AIDS at home.

A similar process was under way in Victoria (the State with the
second highest HIV and AIDS prevalence) and a community group called the
Victorian AIDS Action Committee had been formed. State and Territory governments
soon became convinced that funding gay community NGOs was the most likely way to
prevent further spread of HIV. At the same time, the already established
Australian Prostitutes Collective began to provide condom campaigns for sex
workers and brothels.

There were two key factors which led to success of this
community response. The first was the commitment by government to mobilize the
affected communities and resource them to provide prevention and care. This was
based on the assumption that the communities themselves would produce the most
appropriate campaigns and would reach people at risk in a way that government
could not. It was also assumed that people from marginalized communities would
not present for HIV testing unless their communities supported government
initiatives and were supported by government.

The second important factor was the experience that the gay
community had developed through the law reform process in establishing and
maintaining community organizations. Debate and disagreement flourished in the
affected communities, but the experience in working together in community
organizations meant that decision-making processes were in place and that
progress could be made despite the existence of a wide range of views and
perspectives.

Several years later, the Commonwealth Government commissioned
the development of a national AIDS policy discussion paper in 1988. This paper
was developed following consultation with governments, health workers,
researchers and NGOs. The paper established the first ideas about the
'partnership' response to AIDS in Australia and set out a policy and funding
framework for its establishment (Commonwealth of Australia 1989, 1993, 1996).

CONCEPT OF PREVENTION

Principles of prevention (guidelines and theories used to
develop progammes)

A set of fifteen guiding principles for the design, development
and implementation of successful education and prevention programmes emerged
over the decade 1984 - 1994 as community organizations responded to the crisis.
These principles, set out below, were developed in the wider context of national
government that saw the desirability of political leadership and government
commitment early in the epidemic. Its key symbolic message to the affected
communities was in effect: 'We want you to survive'. This contrasted starkly at
the time with the (then) key message of the US Government to its affected
communities: 'We don't care if you die'.

While Australian governments recognised the desirability of most
education being conducted by affected communities, they set about removing some
of the legal and structural barriers inhibiting prevention efforts. These
measures included:

Within this wider context, the affected communities were able to
focus on developing, testing and implementing the following fifteen principles
for the successful implementation of education and prevention programs.

1. Education designed and delivered by peers is likely to
be more effective than education developed and delivered by other 'external'
agencies - especially in marginalized communities suspicious of government and
its operations.

2. Sustained behaviour change on a wide scale is more
achievable through a programmatic focus on influencing social and community
norms and beliefs, rather than by a focus on changing individual responses.

3. Education programmes should involve the community in
discussion and debate about the range and nature of measures it could take to
reduce the impact of the epidemic.

4. HIV-positive people should be involved in all phases
of programme design, from initial concept through development to content and
delivery.

5. Education should be 'sex positive'.

6. Education should be 'sexuality positive'.

7. Language, images and processes used should be those
already existing in the community involved or generated by that community.

8. Language and images used should be direct, explicit,
understandable and simple.

9. Campaigns should target high-risk behaviours rather
than high-risk groups.

10. Resources and information need to be made available
to assist communities coping with change.

11. The objective of information programmes is to provide
people from affected communities with sufficient information and support to make
their own safe decisions rather than providing a prescriptive set of rules.

12. Education programmes should take great care to share
equally the responsibility for preventing new infections between those infected,
those not infected, and those unaware of their HIV status.

13. Education programmes should be vigorous, continuous
and have the capacity to adapt flexibly to changes in the epidemic and to
changes within communities.

14. Education programme design should be supported by an
active, reflexive social research programme.

15. These principles need to be endorsed and supported by
the political and community leadership.

These principles sit very comfortably within the framework of
the Ottawa Charter. Interestingly, however, in Australia their genesis in the
mid - 1980s arose more from the political and social activism of the gay
community and sex worker communities responding to a health crisis rather than a
considered and systematic application of the Ottawa Charter principles. In
retrospect, it is clear a more rigorous analysis and application of the Ottawa
Charter principles could have allowed a more systematic and all-encompassing
approach in the early stages of the epidemic.

Specific approaches to prevention

AIDS Councils designed campaigns to encourage a 'safe sex
culture' (Dowsett 1990) rather than focus on individual behaviour. The ACON
'Outliving, Outloving, Outlasting' campaign in 1988 is a good example of this
approach. This campaign was made up of a series of elements, campaign materials
such as posters, T-shirts, caps and brochures, accompanied by community
workshops on safe sex, community events, outreach to bars, beaches and discos,
the launch of a safe sex hit song to be played in discos and the placement of
stories about safe sex in the gay press. All of these elements contributed to
the development of a community acceptance of condoms and safe sex.

Endorsement of, and involvement in, these campaigns by community
opinion-makers, commercial venue-owners and community entertainers - in Sydney
this usually means drag artistes - is essential to their success. An early - and
long-term - success has been the establishment of a volunteer outreach team, the
'Safe Sex Sluts'. These volunteers, usually wearing attention-getting drag,
appear at many gay community events and institutions, dispensing safe sex
equipment and advice. This team implicitly manifests many of the principles
articulated above. The Sluts use gay community iconography to re-affirm the
validity of an active sex life and of gay identity. The team reinforces safe sex
behaviour in a non-threatening yet persistent and often imaginatively
challenging way, and it is able to penetrate a wide range of community events
and meeting-places - from large-scale dance parties to smaller events,
commercial entertainment venues and sexual meeting places.

Campaigns carried out by AIDS Councils at this time focused less
on HIV testing and more on safe sex for all, irrespective of HIV status. These
campaigns promoted the use of condoms 'every time' for sex between men. This was
a deliberate strategy to present a simple message in order to increase condom
use in gay communities. The test became available in early 1985, and testing
policies were developed to promote anonymous testing with tight protections on
confidentiality. Pre- and post-testing counselling policies were also put in
place. Prevention campaigns were then developed in a context of the availability
of free anonymous HIV testing and counselling. Gay men presenting for HIV
testing were taught skills in negotiating safe sex with partners in HIV
counselling sessions. This often involved striking a 'contract' with their
existing primary partner for no condom use within the primary relationship but
strict condom use outside the relationship. This was accompanied by a discussion
of the skills required to disclose to the primary partner if there had been
unsafe sex outside the relationship so as not to put him at risk. This system of
negotiation was later described as 'negotiated safety' by social researchers
(Kippax et al. 1993a).

At the same time, sex worker and injecting drug user groups were
emerging and designing campaigns and initiatives to target sex workers and
users. Sex worker groups used outreach strategies to visit streets and brothels
in order to distribute condoms and water-based lubricant and to talk with sex
workers about AIDS and sexual health. IDU groups designed campaigns to reduce
needle-sharing and to promote the availability of clean injecting equipment
through mobile and fixed-site needle and syringe exchange services. Needle
exchanges, which had been established in most States and Territories by 1988,
were initially politically sensitive; however, they represented a significant
policy shift towards harm minimization and a recognition of the public health
risks associated with injecting drug use. At that time, there was a fear that
HIV infection, mostly contained within the gay community, would spread to the
'general community' though the 'bridge' of sex workers and injecting drug users.
This strengthened the resolve of governments to support sex worker safety and
needle and syringe exchange programs.

Relationship with research institutions

An important collaboration between the AIDS Council of New Wales
and the School of Behavioural Sciences at Macquarie University, Sydney,
developed early in the epidemic. Researchers and community organization
activists worked closely together to develop research questions and to design
studies that would provide guidance to both community organizations and
government for the design of campaigns and programmes. Various steering
committees, comprising researchers, community workers and government
bureaucrats, were established and provided a forum for discussion of social
research needs. Several important studies emerged from this collaboration and
continue to provide essential information to guide campaigns and programs. (Much
of this research has been summarized in Dowsett 1994.)

The collaborative approach had several distinct advantages.
Research questions were developed in response to the changing context of HIV
prevention in the affected communities; researchers could gain access to the
subjects they needed for their work; governments accepted the community's
recommendations for changes to campaigns and programmes as they were backed up
by research findings. This collaborative research model requires a high level of
cooperation and trust between researchers and communities. It is a relationship
of 'managed tension': communities generally want quick answers so that they can
respond to changing circumstances, researchers want rigour so that their
research results can be trusted; community processes are inclusive and
collaborative, the academic environment is highly competitive and has its own
pressures, such as the need for peer review. The early collaboration between
Macquarie University and ACON was one factor that eventually led to the
establishment of a National Centre for HIV Social Research (now the National
Centre in HIV Social Research) which has played an important role in Australia's
AIDS response. The Commonwealth Government also funded research through its
traditional academic research funding mechanisms, with earmarked funds so as to
develop research outside that done in the national centres1, and a
number of independent academic researchers have worked in a number of States and
Territories on social and behavioural research projects on behaviour change,
prevention education, needs assessment and evaluation. The combined efforts of
these independent researchers and the national HIV research centres has provided
Australia with a very successful and focused research programme as an integral
part of the national AIDS strategy. Research collaboration was greatly assisted
by the employment of researchers with HIV and researchers from the affected
communities in many of these research programmes. These people brought an
additional perspective to the work of researchers and allowed for the
development of strong links between the research and PLWHAs.

1 There are three national HIV research
centres: National Centre in HIV Virology; National Centre in HIV Social
Research; and National Centre in HIV Epidemiology and Clinical
Research.

COMMUNITY/GOVERNMENT PARTNERSHIP

The development of the partnership

NGOs were originally established from within the metropolitan
gay communities in response to the diagnosis of people with AIDS. These small
community groups provided the initial volunteer care and support for people with
AIDS, raised money to assist people with AIDS, and began to develop information
and education materials about AIDS. These NGOs gradually secured funding from
government as it became clear that there were significant numbers of people with
AIDS in the gay community. Government funds were used by NGOs to develop
campaigns and education materials aimed at informing gay men about safe sex.
Gradually, governments in the most affected States and Territories established
funding programmes to assist NGOs to reach gay communities, injecting drug users
and sex workers.

A national AIDS policy discussion paper developed in 1984
proposed the establishment and funding of a partnership response to AIDS, and
brought together governments, health workers, researchers and NGOs from the
affected communities through the establishment of a National Advisory Committee
on AIDS to oversee the national response to public education awareness and
community needs. This committee worked in tandem with a medical advisory
committee in providing the Commonwealth Government with advice. These two
committees were eventually joined together to form the Australian National
Council on AIDS (recently renamed the Australian National Council on AIDS and
Related Diseases to represent more accurately the breadth of concerns of the
third national strategy).

Structure of the partnership

The community/government partnership operates at several levels
and its structures are mirrored at these levels. At a national level, the
Commonwealth Health Department provides funding to the national AIDS NGO (AFAO)
but does not sit on its management committee. AFAO negotiates an annual plan of
activities with the Commonwealth and provides an annual report on performance
indicators and outcome measures, but AFAO is accountable to its member
organizations (the State and Territory AIDS NGOs and national sex worker, IDU
and PLWHA NGOs).

The relationship at this level is probably best described as a
'creative tension'. AFAO has autonomy to develop its policies and positions on
issues independently and has often publicly expressed its dissatisfaction or
disagreement with government policy. AFAO generates its policies and positions
by consulting with its member NGOs. In general though, the Commonwealth's AIDS
policies and positions are arrived at using a collaborative and consultative
process, and there is a general understanding in the partnership that either
side will attempt to resolve and policy differences directly before involving
the press or community mobilization strategies and/or protests. There is also a
generally accepted policy of 'no surprises' in the partnership, i.e. no public
criticism of the other partner without warning them beforehand that this public
criticism is going to be made. This has led to a high level of trust and
cooperation between members of the partnership. It would be unusual for either
side to arrive at a policy or position on a controversial AIDS issue without
first consulting the members of the partnership and discussing the position that
is proposed. For example, on major issues, such as HIV testing policy or HIV
vaccine development policy, the Commonwealth Government has undertaken a
consultative process to arrive at a position.

AFAO and NAPWA are represented on key decision-making and
consultative bodies such as ANCARD, the principal national advisory committee to
the Commonwealth Minister of Health, and its various subcommittees on research,
education and clinical trials. AFAO is also represented on the Intergovernmental
Committee on AIDS and Related Diseases, the body responsible for communication
and coordination between the Commonwealth, State and Territory governments on
HIV/AIDS issues.

Campaigns and other materials produced are generally presented
to government for approval, although the level of scrutiny varies according to
the political context and the level of trust between government and community
organizations. At a State and Territory level, AIDS Councils, IDU, PLWHA and sex
worker organizations are generally funded by, and work in partnership with,
their State or Territory governments, even if the funding originally came from
the Commonwealth. Many States and Territories have their own Ministerial AIDS
Advisory Committees to advise Health Ministers on policy and programme issues.
Community organizations are generally represented on these key decision-making
bodies. Policies regarding the approval of campaign materials vary from State to
State, but AIDS Councils generally develop comprehensive campaign briefs to
inform government of the rationale for particular campaigns. State and Territory
community groups also develop strong links with service providers at State level
to assist them in providing care and support services.

Although these structures are important, the most important
aspect of the partnership has been the commitment by government and community to
work together to make the partnership work. Building trust and mutual respect
takes time and commitment. Community NGOs and government have different basic
aims, different sources of accountability, different processes for
decision-making and different constituents. While governments often see NGOs as
unpredictable and reckless, and NGOs see government as conservative and fickle,
these two sectors have had to learn methods of communication and trust and these
have been tested along the way as issues emerged.

Although these two sectors have worked closely together in this
partnership it has been important for each to remain separate and autonomous.
Community-based NGOs have to maintain their connection with their communities if
they are to represent and serve them effectively. They cannot be, and cannot be
seen by their constituents to be, too close to government. HIV/AIDS community
groups have maintained this separation by ensuring that policies and positions
on issues are developed in consultation with affected communities and that
people with HIV occupy a central place in their decision-making structures.

Role of community in the partnership

At all levels of the partnership, the community organizations
have a key role in bringing the perspective of people with HIV, people at risk
and people affected by HIV to the decision- and policy-making setting.
Governments decided quite early in the Australian HIV epidemic that access to
the affected communities and the trust of these marginalized communities was
only going to be achieved by funding and maintaining a relationship with NGOs
formed from within those communities. Community NGOs have been responsible for
the design and implementation of education campaigns and other initiatives to
maintain safe sex behaviour and safe needle use. These initiatives have
included:

· the provision of
support groups for people with HIV and people at risk;· outreach to bars, dance parties and other community
events;· work with sex venues such as
brothels, saunas and video clubs;· provision
of information to community social and sport clubs;· groups for ethnic sub-communities within the gay
communities;· outreach to sites of sex
between men such as public toilets, parks, etc.;· services for subgroups within the community such as
deaf gay men.

Community-based NGOs also provide care and support services for
PLWHAs and their carers. These services train and support volunteers from within
affected communities to provide care at home. This has a spin-off
education/prevention effect within communities, as volunteers receive training
and support to assist them in maintaining safe behaviour or in dealing with
their HIV status. These NGOs also provide essential information to government to
assist in policy setting. They advocate on behalf of people with HIV and people
at risk to ensure that discrimination and stigma are minimized, health service
quality is maximized and access to HIV treatments is ensured.

Community NGOs also play a key role in producing and
disseminating information to their communities on risk, HIV transmission, HIV
treatments and services. This information is presented in language and formats
that are more likely to be understood by and acceptable to affected communities.
Publications have included a bimonthly, issues-based magazine (the National
AIDS Bulletin), a quarterly publication on legal issues (HIV Legal
Link), monthly and bi-monthly treatments information newsletters
(Positive Living and HIV Herald) and community newsletters for sex
workers and injecting drug users.

Involvement of PLWHAs

It is often stated that people with HIV have played a central
role in the national response to HIV in Australia. Although this is true in the
main, creating and maintaining a place for people with HIV in the response has
not always been easy, and people with HIV still find that their place is not
guaranteed. In the early years of the epidemic, people with HIV were
predominantly involved in HIV care and support programs and advocacy for HIV
treatments and human rights. Over a period of time, there has been considerable
discussion and debate around their inclusion and involvement in the development
of HIV prevention campaigns and initiatives, including the use of specific
messages relevant to people with HIV and imagery that depicted people living
with the virus. These issues were worked out over time; however, they
highlighted a tension in community prevention campaigns in Australia between the
need to target the gay community and the fear that using images of people with
HIV would 'blame the victim' for HIV transmission and place additional stigma
and blame on people with HIV. PLWHA groups are now actively involved in the
design of prevention campaigns and in the use of HIV positive imagery and
messages in prevention campaigns.

People with HIV and the groups that represent them also play a
key role in policy and programme development at all levels of the partnership.
The involvement of people with HIV relies heavily on the existence of laws and
policies that protect their privacy and provide protection against stigma and
discrimination. Until these were in place in Australia, it was difficult to
maintain the contribution of people with HIV to the response as their
participation required a level of public disclosure of their HIV status. The
availability of people with HIV who are prepared to speak publicly about their
HIV status has been of particular value. Prevention and care messages delivered
by HIV positive people have a particularly strong impact. These people also act
as role models for other people with HIV. HIV positive 'speakers bureaux', which
train HIV positive people to present information on HIV to schools and community
groups, have been successful in reducing stigma and discrimination and in
increasing HIV awareness.

MEASURES OF SUCCESS

There are several indicators of success for education/prevention
initiatives. At a micro level, campaigns are focus-tested, process-evaluated and
their impact on communities is measured. Community NGOs evaluate information and
support interventions using client satisfaction, impact evaluation and other
measures. Initial behavioural studies of gay men undertaken in 1986 (Kippax et
al 1993b) indicate a significant behaviour change had occurred among gay men in
New South Wales. Since these, there have been longitudinal studies and
'snapshot' surveys that indicate sustained changes in risk behaviour and assess
the impact of the overall prevention program. The Sydney Gay Men and Sexual
Health (SMASH) cohort provides ongoing information on patterns of risk-taking
among Sydney gay men. This study has been replicated in Melbourne and Brisbane
(the two cities with the next largest gay communities after Sydney). In
addition, 'snapshot' surveys have been carried out in HIV testing clinics and at
gay community events. There have also been two nation-wide anonymous telephone
surveys, which have provided information on risk activities among non
gay-identified homosexually active men. Studies and surveys of injecting drug
use patterns have also been conducted.

The first and the second national HIV/AIDS strategies have been
comprehensively and independently evaluated. The evaluation of the second
National Strategy was carried out in 1995. The report noted that the reduction
in new infections to date among gay men and the maintenance of a low incidence
among injecting drug users have been major achievements. However, the evaluation
report pointed out that, with current trends, the partnership would not reach
its stated target of a reduction in new infections to two per 100,000 people per
year. The report urged the partnership to develop new strategies to reduce new
infections further. The report also noted the need to design new approaches to
deal with the emerging epidemic among Australia's indigenous communities. These
communities had not been comprehensively targeted in the first two national
strategies.

AT WHAT COST?

Expenditure on prevention programmes

The national AIDS strategies have framed the allocation of
specific funding for HIV/AIDS through the public health program. The
Commonwealth allocates the majority of this HIV/AIDS funding to the States and
Territories using a formula based on prevalence and general population size.
Funds are distributed at State and Territory level between government and
non-government services. States have, until recently, been required to match the
Commonwealth allocation on a 1:1 basis. Some States, such as New South Wales,
which has the overwhelming majority of people with HIV, have committed funds
well beyond the required 1:1 match. Funding for hospital care is met through
Medicare, a national funding agreement between the Commonwealth Government and
States and Territories, and pharmaceuticals are funded through a national
pharmaceutical funding scheme.

The first national AIDS strategy called upon States and
Territories to allocate 50% of AIDS funding to education/prevention and 50% to
care and support services. The second national strategy, in recognition of the
increasing number of people with HIV requiring care, shifted this proportion to
60% for care and support, and 40% for education and prevention. To some extent,
these proportions had little meaning as the definition of education and
prevention was not clear and often included provision of HIV testing and sexual
health services. Most targeted education and prevention campaigns have been
carried out through NGOs and the proportion of NGO funding has remained low.

The first national strategy (1989 - 1993) allocated
approximately AU$8 million per year for four years for education and prevention.
This was matched dollar for dollar by the States. Under the first national
strategy, approximately 8% (AU$3.5 million per annum) of the education and
prevention budget was allocated to State and Territory AIDS Councils for gay
men's education. The Commonwealth also kept back some funds for national
education campaigns. In the second national strategy (1992/1993 - 1995/1996)
AU$24 million was allocated to States and Territories, which was matched 1:1.
The strategy called for a minimum of 40% of the matched funding allocation to be
spent on education and prevention programs, with priority given to funding
community organizations working with high-risk target groups. The strategy did
not specify what proportion of funds as to be allocated to NGOs at State and
Territory level.

The third national AIDS strategy (1997/1998 - 1999/2000) was
produced in the broader context of related communicable diseases and sexual
health. It allocates a similar annual amount overall but does not specify how
the allocation is to be distributed within States and Territories. It identifies
gay men and other homosexually active men as the primary target for education
and prevention. The strategy is being implemented in an environment of health
service reform, which is giving States and Territories increased autonomy in
relation to health service provision and increased flexibility for budget
allocation and priority setting, but within a much broader definition of public
health goals, one that focuses less on specific diseases. This is causing some
concern in HIV organizations as States have increased freedom to set public
health priorities. There is a fear that the gains made in HIV prevention will be
seen as achieved already, and that HIV prevention and education programmes will
be scaled down.

LESSONS LEARNED

There have been many lessons learned in the response to HIV/AIDS
in Australia, and the most important is that the partnership between governments
and communities is a dynamic one that needs nurturing and continued resourcing.
This partnership is referred to constantly as the secret of Australia's
successful HIV/AIDS response. There is a danger that the partnership sometimes
becomes just a collection of sectors, each with different approaches, processes,
priorities and contributions, rather than a dynamic relationship between these
sectors. The partners need to be able to bring their respective contributions
and perspectives without losing their essential identities. Community
organizations are sometimes accused by their constituents for appearing to be
'in bed with government' or 'just another arm of bureaucracy'. They are also
sometimes accused by government as representing the 'feral' community. It is
important for community organizations to maintain their links with the
communities they serve. It also important for governments to allow a level of
disagreement and debate within the partnership without feeling that the
partnership might threaten their existence.

It has been easy at times to take this partnership for granted,
not to respect the individual contributions of its members and to attempt to
make the partnership a homogenous entity. An example of the neglect of the needs
of the partnership is the occasional misunderstanding of processes of community
representation. Government often calls upon community organizations to provide a
representative for a decision-making body. It often requires the name of the
representative within a few days of the request. It has an expectation that the
community organizations will dip into its ranks and pull out a suitably
qualified representative. It becomes impatient when the community NGOs say that
they have processes for appointing representatives, which involve calling for
expressions of interest from affected communities and making a choice from the
expressions of interest received. Government often states that it wants a
representative who will behave 'reasonably' and not cause problems on the
committee, and it sometimes names the person it would prefer. It is important
that government understands the processes of the community sector and
understands that community NGOs maintain their links with their communities by
maintaining transparent and fair decision-making processes. Although this
appears a reasonably trivial example, it is an indicator of the level of
understanding needed of the difference between government and community, and of
the level of autonomy that must be afforded members of the partnership.

Beyond this issue of the relations between the partners, there
are a number of basic ideas that underpin good health promotion, learned from
the Australian experience:

1. Campaigns are more than just posters and pamphlets.
Since the beginning of the Australian AIDS response, NGOs produced campaigns
made up of a complex set of elements such as printed resources, merchandizing,
strategic community media placements, workshops, seminars, support groups,
community outreach and other initiatives. The posters and pamphlets conveyed
essential information, but also acted as symbols or reference points for the
other elements of the campaigns. There has been a tendency at times to produce
campaigns that are constituted only by posters and pamphlets and which lack the
other community elements. There is a growing recognition that these streamlined
campaigns have less impact than campaigns that include a set of elements aimed
at several aspects of community life.

2. Targeting of campaigns is important. Campaigns aimed
at members of affected and marginalized communities have often necessarily
contained explicit images of sex between men or of injecting drugs. The
effectiveness of the use of explicit materials has been clearly demonstrated.
These campaigns, howver, are sometimes seen to cause problems if they become
available to people outside the main target group, for example, when sexually
explicit materials targeting gay men reach school-age young people. These
situations can result in political incidents and challenge the stability of the
partnership, as governments withdraw their support for a campaign in fear of a
political backlash, irrespective of public health needs, and move into damage
control. Incidents such as theses damage the working relationship between
community NGOs and governments. These can generally be avoided by establishing
agreed distribution policies and by community NGOs preparing detailed written
briefs for each campaign.

3. Campaigns are best designed and delivered by members
of the affected communities targeted. This has been referred to in the
principles listed above, but has also been a key lesson learned. The wider the
gap between the campaign developers and the target group the less likely that
campaign will produce the required outcomes.

4. Shortcuts in campaign development and implementation
reduce the quality of the campaign outcomes. In the haste to get campaigns 'on
the streets', it is tempting to take short cuts in design and development or in
the implementation of campaigns. The process of the development of a campaign is
sometimes as beneficial to the target community as the campaign itself. There is
much to be gained from the inclusion, debate and discussion that accompanies
campaign development. Campaign issues often change as the campaign unfolds.
Focus testing is important, as it is easy to miss the needs of the target
community or confuse the message. An evaluation of the process of campaign
development is sometimes as important as the evaluation of its impact. There is
also little value in developing a wonderful campaign that does not actually
reach target communities because of shortcuts in implementation. Communities
need to be prepared for their participation in the campaign and given sufficient
resources to participate.

5. Peer-based education is likely to be more effective
than education developed and delivered by other 'external' agencies, especially
in marginalized communities suspicious of government programs.

WHERE TO FROM HERE?

The AIDS response in Australia has developed over thirteen
years. There have been many changes in the issues facing people with HIV/AIDS
and people at risk, and the partnership has had to remain flexible and strong.
The increased success of combination therapies has had a significant effect on
the response. There is a temptation to feel that AIDS has been dealt with and no
longer presents a threat. New generations in the affected communities have not
had such a close association with HIV/AIDS and may see it as less relevant or
not fear it as much. Other issues, such as high rates of sexually transmissible
diseases in some communities, and the emergence of an epidemic of hepatitis C,
present public health officials and government with new priorities. There is a
chance that these priorities will dominate public health policy and funding, and
that gains made over the last twelve years in HIV prevention and care might be
jeopardized. The rate of new HIV infections in Australia has been stable at
approximately five hundred per year for some time. If this rate is to be
reduced, governments and communities will have to continue their work and find
new ways to assist individuals and communities to avoid HIV transmission.

There are also broader changes in train that affect the
relationship between governments and NGOs. The move towards smaller government
and to the contracting out of health care services places NGOs in a different
role with government. Competition is encouraged between NGO providers. It is
possible that the long-standing, co-operative relationship between government
and community organizations may be threatened by the emergence of new service
providers, one-step removed from government but with no particular community
connection. This is particularly a problem in health promotion and community
development programmes that rely on connections with communities for their
success.

There is also a tendency towards mainstreaming or integration of
services and approaches. Although this has some merit at government and health
service level, it is difficult to implement at community level. Community NGOs
have relied on their success in mobilizing the energy and resources of affected
communities. It is not clear that combining communities of people with HIV with
people affected by hepatitis C (irrespective of possible overlap), for example,
would be an effective model. Although there is much to be gained from the
sharing of experience and expertise between these communities, combining them at
community level may not always produce better health outcomes.

This case study has attempted to summarize the structure and
functioning of the partnership response to AIDS in Australia. It has highlighted
the lessons learned and the key tensions of the partnership between government
and NGOs. The most difficult aspect of the partnership to portray is the nature
of the relationships which make up the partnership. This is a partnership which
requires continual nurturing, goodwill and commitment. Like all partnerships, it
withers if it is taken for granted. The ongoing success of this partnership will
be dependent on the desire of all parties to continue to participate, to work
together and not to lose sight of each other's essential contribution.

References

Commonwealth of Australia 1989, National HIV/AIDS Strategy, A
Policy Discussion Paper, Canberra, Australian Government Publishing Service.

Dowsett, G.W. 1990, 'Reaching men who have sex with men in
Australia. An overview of AIDS education: community intervention and community
attachment strategies', Australian Journal of Social Issues, vol. 25, no.
3, pp. 186 - 295.